Assessment of childhood immunization services at private healthcare facilities in Indonesia: a case study in a highly-populated city

Introduction The need to enhance the utilization of the private sector for immunization programs in Indonesia while maintaining the high quality of services provided is evident. This study aimed to rapidly assess immunization services at private healthcare facilities in Indonesia by using Bandung, the most densely populated city, as the reference case. Methods Initially, a situation analysis was conducted by collecting data from selected healthcare facilities (n = 9). Furthermore, a qualitative study was taken into account by developing framework approaches and conducting interviews with different layers, such as mid-level managers at healthcare facilities (n = 9), professional organizations (n = 4), and public stakeholders (n = 7). Results The situation analysis showed that private healthcare facilities had provided sufficient time for essential childhood immunization services with adequate staff. Nevertheless, the number of limited staff the Ministry of Health (MoH) has trained remains a programmatic problem. Furthermore, private healthcare facilities have used the MoH guidelines and additional internal guidelines for immunization services as the primary reference, including in the efforts to provide complete and reliable equipment. Vaccine availability at private healthcare facilities is manageable with an acceptable out-of-stock level. The results of our interviews highlighted three key findings: the lack of coordination across public and private sectors, the need for immunization service delivery improvement at private healthcare facilities, and the urgency to strengthen institutional capacity for advocacy and immunization systems support. Conclusion Even though private healthcare facilities have been shown to make a modest contribution to childhood immunization services in Indonesia, efforts should be made to expand the role of private healthcare facilities in improving the performance of routine immunization programs.


Introduction
The Expanded Program for Immunization (EPI) in Indonesia is falling short of the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) target to reach 90% of children under the age of 1 nationwide and at least 80% in every province by 2020 (1,2). The Coronavirus Diseases 2019 (COVID-19) pandemic has dramatically impacted routine immunization performance in Indonesia (3,4). The national immunization program data showed a decline in the coverage of basic immunization programs from 93.6% in 2020 to 84.5% in 2021, indicating that thousands of children will be at risk of increased morbidity and mortality from the outbreaks of vaccine-preventable diseases (VPDs) (5). Coverage of immunization is at risk because restrictions have already led to temporary closure and service suspensions among integrated public healthcare facilities as the backbone of routine maternal, newborn, and child services in Indonesia. On the other hand, subsequent reports showed that the proportion of immunization services at private healthcare facilities has been growing significantly (6,7). Despite the transition to universal health coverage, private healthcare facilities still dominate Indonesia's healthcare system, where 64% of Indonesia's hospitals are private (8). A recent immunization perception survey in Indonesia showed a high demand for safe and timely vaccination services during the COVID-19 outbreak (5). Respondents strongly supported government policy to continue the immunization services with safety precautions, and private healthcare facilities are preferable places for getting immunization services (5). This preference for private healthcare facilities might be due to the proximity of private healthcare facilities to the people, the constant availability of healthcare professionals at private healthcare facilities, and poor services in some public healthcare facilities (9). This preference for healthcare facilities informed the need to enhance the utilization of the private sector in immunization programs while maintaining the high quality of services provided. In addition, from a global perspective, the private sector performs various tasks and activities to support national immunization programs. In low-and middle-income countries (LMICs), it supports the delivery of immunization services and promotes early acceptance of new vaccines before their introduction and widespread use by the public sector (10).
This study aimed to rapidly assess immunization services at private healthcare facilities in Indonesia using Bandung as the reference city. As the capital of West Java Province, Bandung is considered the most densely populated city in Indonesia, with a density of over 14,000 people per square kilometer (11). The latest basic health research conducted by the Ministry of Health (MoH) in 2018 reported that the complete basic immunization coverage for children aged 12-23 months in this region was only 58% (12). Compared with other regions, this coverage was lower, possibly caused by underreporting data from private healthcare facilities. Hence, the objectives of this exercise were to identify gaps, gather perceptions of relevant stakeholders, and prepare for the scale-up of immunization activities at private healthcare facilities.

Methods
A review of available data, existing policy, legal review, and published literature was applied as the initial step to analyze the situation of immunization services at private healthcare facilities. In addition, primary data were collected by identifying problems and gaps in vaccine service delivery, human resources, and supply chain management, and delivering questionnaires to 9 of 30 (30%) private healthcare facilities that deliver immunization services in Bandung (13). Applying WHO's guidelines on Service Availability and Readiness Assessment (SARA) to assess service readiness for childhood routine immunization services at private healthcare facilities, several significant variables were taken into account in the questionnaire by focusing on basic amenities and equipment, such as general characteristics (e.g., service days per month, hours of service in a typical day, staff involved in vaccination, and outreach services available), staff and training (e.g., guidelines for EPI and staff trained in EPI), equipment (e.g., cold boxes/vaccine carriers with ice packs, refrigerators, sharp containers, single-use standard disposable or auto disposable syringes, continuous temperature monitoring devices in the refrigerators, energy sources and power supplies for vaccine refrigerators and immunization cards), and vaccine availability (e.g., current stock and stock-outs in the past 3 months) (14).
Furthermore, a qualitative study was considered by developing framework approaches and conducting interviews with different layers. Applying WHO's framework on monitoring the immunization system (15), in-depth interviews with mid-level managers were conducted in 9 selected private healthcare facilities, representing a type A hospital (n = 1; TAH), type B hospital (n = 2; TBH1 and TBH2), type C hospital (n = 2; TCH1 and TCH2), vaccination house (n = 2; VH1 and VH2), and private clinic (n = 2; PC1 and PC2). These respondents comprise private-for-profit (n = 7) and private-not-forprofit institutions (n = 2). Questions focused on five components of the immunization system: service delivery, vaccine supply, quality, and logistics; surveillance and monitoring; advocacy and communication; and program management (15). Each component has different vital points to be explored during the interview process (see Table 1).
Following a framework by Tan et al. on the significant achievements related to immunization advocacy to strengthen the immunization outcomes in private sectors in Indonesia (6), in-depth interviews with healthcare professional organizations and public stakeholders were conducted, focusing on efforts to increase coordination across public and private sectors, to improve service delivery, and to strengthen institutional capacity for advocacy and immunization systems support. As an alternative to get some insights from professional organizations and public stakeholders on these three efforts, interviews were conducted with healthcare workers' organizations (n = 2; Indonesian Doctor Association/IDA and Indonesian Pediatrician Association/IPA), hospital associations (n = 2; Indonesian Hospital Association/IHA and Indonesian Private Hospital Association/IPHA), central government, which was represented by Indonesian MoH (n = 1; Directorate of Immunization Management/DIM), and local government, which was represented by Bandung District of Health/DoH (n = 6; Department of Disease Prevention and Control/DDPC, Department of Healthcare Services/ DHS, Department of Human Resources/DHR, Department of Public Health/DPH, and two primary healthcare centers/PHC1 & PHC2).

Situation analysis
The results showed that most private healthcare facilities (56%) provided essential immunization services for children at >6 h per day and < 25 days per month. The number of vaccination staff the MoH had trained varied from 2 to 16 members of staff. Most private healthcare facilities (67%) applied guidelines for immunization services and developed additional internal guidelines. Regarding vaccine availability, the majority of healthcare facilities confirmed that they have available vaccines (e.g., MR, BCG, polio, pentavalent, PCV, IPV, and hepatitis B Frontiers in Public Health 03 frontiersin.org vaccine) for essential childhood immunization services at that moment. Only a few healthcare facilities confirmed that they did not have the MR (11%), PCV (11%), and IPV vaccine (33%). In the context of experiencing vaccines being out of stock in the last 12 months, all healthcare facilities mentioned that they had these experiences for MR (22%), BCG (44%), polio (33%), pentavalent (33%), PCV (22%), and IPV vaccines (22%). Most healthcare facilities applied self-procurement for PCV (67%), IPV (56%), and hepatitis B vaccines (56%). In particular, most of them (67%) applied a combination of self-procurement and government programs for MR, BCG, polio, and pentavalent vaccines (see Table 2).

3.2.
In-depth interviews with mid-level managers in healthcare facilities 3 "This number is too low. The major possibility is data from independent medical practice have not been included (VH1). " • Unclear report on vaccine utilization "To our knowledge, there is no mandatory to report the use of vaccines to the DoH. (TCH1). " "Regarding the use of vaccines that are self-procured and obtained from the government, reports have to be submitted routinely every month to the DoH (VH1). " "We only report the use of vaccines procured by the government (PC2).
• Various types of agreements between the government and private sectors allow private healthcare facilities to use vaccines procured by the government "We have a written contract with the DoH to get vaccines from the primary healthcare center (PC2). " "There is an official document, and we are also encouraged to send monthly report [sic] to the primary healthcare center that gives us vaccines (TBH1). " "We do not have any contract or cooperation documents with the DoH or the primary healthcare center (TCH1). " • Differences in the frequency of immunization services monitoring "The DoH, through the primary healthcare center, conducted a routine monitoring of immunization services and vaccine supply chain in our healthcare facility (TBH2). " "The primary healthcare center supervised and monitored our immunization services and vaccine supply chain management only once at the beginning (VH2). " "When the DoH visited our healthcare facility for supervision and monitoring, they only asked about immunization technicalities, such as the standard operating procedure of vaccine cold-chain (TCH1). " • Various types of coverage, drop-out rate, and incidence of VPDs monitoring "Monitoring coverage and the drop-out rate are done through the patients' vaccine books. We send parents a reminder of the vaccination schedule (PC1). " "We use a vaccine diary or passport to maintain coverage and minimize drop-out rate. In particular, most doctors and their nurses have initiatives to ascertain patients' attendance for vaccination one day before the schedule of appointment (TAH). " "We monitor the incidence of VPDs through updated news from media, data on the use of vaccines, and patient's medical record (TBH1). " "We do routine monitoring related to the incidence of VPDs.
We have an interesting story during the COVID-19 pandemic where we found a significant increase of PCV immunization requests from patients (TCH 2). " 3.2.2. The need for immunization service delivery improvement at private healthcare facilities • Vaccine availability and the number of patients' visits are critical indicators of immunization services at private healthcare facilities "All private healthcare facilities confirmed that there are two key indicators of their immunization services, such as vaccine availability and number of patients' visits. " "We believe that our brand is strongly associated with good services, and it helps us deliver immunization services as well (TCH1). " • Impact of the pandemic on routine immunization services "The availability of vaccines is limited because of the pandemic, such as pentavalent and polio vaccine (PC1). " "There is a significant decline in the number of hospital visits, possibly due to the stigma of visiting hospital is not safe, so many patients turned to private clinics for getting immunization services (TBH2). " • Impact of national immunization plan, such as PCV, which will be included in the national program in 2024, on immunization services at private healthcare facilities "It will have an impact on reducing our revenue, but we always commit to supporting the national immunization programs in achieving the targeted coverage (TBH1). " "Depending on the parents' choices between getting the free vaccine from public healthcare facilities or visiting private healthcare facilities with additional costs for certain reasons (TBH2). " • Availability and sustainability of public immunization services need to be improved "Up to now, we can request routine vaccines from the DoH. If they have vaccines out of stock, we do self-procurement through official distributors (TAH)".

Discussion
Immunization services at public healthcare facilities in Indonesia were disrupted at 65-90% because of the pandemic (3). In contrast Frontiers in Public Health 10 frontiersin.org with public healthcare facilities, the demand for immunization services at private healthcare facilities has been increasing significantly in the last 2 years. This situation occurred in many countries, highlighting the need for various contributions from the private sector, including private healthcare facilities. In Indonesia, childhood immunizations are a package of essential health services provided and financed by the government. The government's ability to deliver these services is directly affected by governance, administrative capacity, and economic factors (10). In particular, health financing, infrastructure, and competing health priorities challenge the desire to provide more comprehensive immunization services (16). Hence, the role of private healthcare facilities in vaccination coverage and practices should be accelerated by enhancing interaction between public and private sectors, the level of monitoring, and the degree of regulations imposed on private healthcare facilities (17).
Our study is the first to assess immunization services at private healthcare facilities in Indonesia. Nevertheless, it has several limitations, and one of the significant limitations is about setting of the study. Firstly, we only considered one respondent from one institution in our in-depth interviews. To ascertain that the critical person is enough to give a complete account of the situation of interest, we listed and ranked potential participants who could meet our purposes. Secondly, we focused our study on Bandung, the capital of West Java Province, the most populous province in Indonesia with a relatively low childhood vaccination coverage (12). Using this such a region as the case study, we expect the results of this study to be one of the references to enhance the role of private healthcare facilities in delivering immunization services. The situation analysis showed that private healthcare facilities had provided sufficient time for essential childhood immunization services with adequate staff. However, the limited staff the MoH has trained remains a programmatic problem. Furthermore, private healthcare facilities have used the MoH's guidelines and additional internal guidelines for immunization services as the primary references, such as providing complete and reliable equipment. Vaccine availability at private healthcare facilities is manageable, with the out-of-stock vaccine level remaining acceptable.
The qualitative evaluation provided a critical view of immunization services at private healthcare facilities by gathering perceptions of healthcare workers and other relevant stakeholders. Applying WHO's framework for monitoring the immunization system (14), we collected information from mid-level managers at private healthcare facilities by focusing on service delivery, vaccine supply, quality, and logistics; surveillance and monitoring; advocacy and communication; and program management. This evaluation highlighted three key findings: the lack of coordination across public and private sectors, the need for immunization service delivery improvement at private healthcare facilities, and the urgency to strengthen institutional capacity for advocacy and immunization systems support. In the context of coordination across public and private sectors, we found several interesting findings, such as the importance of legal agreements between the DoH and private healthcare facilities and the urgency for private healthcare facilities to report the use of vaccines from self-procurement and government programs. Another critical issue is immunization service delivery at private healthcare facilities. All private healthcare facilities confirmed that there are two critical indicators of their immunization services, such as vaccine availability and the number of patient visits. As most private healthcare facilities apply a combination of vaccine selfprocurement and government programs, support from the government in terms of vaccine availability is significant. When private healthcare facilities can avoid out-of-stock vaccines, the performance of immunization services can be maintained, and the number of patient visits can be increased simultaneously. The last concern is about institutional capacity for advocacy and immunization systems support. Private healthcare facilities require regular DoH supervision and monitoring to improve immunization services, including vaccine supply chain management continuously.
By conducting in-depth interviews, we gathered insights from healthcare workers' organizations, hospital associations, and both central and local government. Feedback from professional organizations and public stakeholders is required to find out solutions related to those findings. Several promising alternatives could be identified. Firstly, the government should publish a comprehensive technical guideline for immunization services at private healthcare facilities immediately to increase coordination across public and private sectors (18, 19). Even though several central and local government regulations have been launched, they should have considered technical and practical issues. Secondly, technology interventions to develop one-stop-service applications can be used as an alternative to improve service delivery for immunization programs in public and private healthcare facilities (20, 21). Lastly, comprehensive monitoring and supervision must be conducted regularly through more detailed SOPs to maintain the quality, safety, and efficacy/effectiveness of vaccines. Given limited human resources, the Internet of Things can assist healthcare facilities in reporting data and the DoH officers in supervision and monitoring (22,23).
All countries worldwide have variable degrees of government engagement with the private sector to deliver immunization services. In most LMICs, publicly funded immunization services are mainly provided by public healthcare facilities, but the more significant contribution from private healthcare facilities to deliver these services is essential (24, 25). It has been known that private sector engagement can add value to the health system at various levels, including increased access to skills and expertise, operational efficiencies, increased innovation, shared risk, and allowing the government to focus on its core competencies (24, 26). This engagement is significant for Indonesia as a country with limited resources to achieve national health and vaccination goals (24). More effective engagement between the public and private healthcare sectors could improve the performance of health systems by providing better policies, regulations, information sharing, and financing mechanisms (27). If private healthcare facilities already provide a significant proportion of childhood vaccinations, engagement should be focused on service quality issues. If they do not contribute a significant proportion of vaccinations, a potential role for them to expand the reach of public healthcare facilities should be accelerated. Hopefully, this study could assist the stakeholders in the decision-making process related to improving immunization services in Indonesia.

Data availability statement
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.